EasyStand Warranty Registration

Thank you for purchasing one of our EasyStand standing frames. Please take a few moments to complete and submit the warranty registration form below. As thanks for helping us to serve you and our other customers more effectively, we will send you a free gift (Please note that all necessary information must be complete and the free gift is available in the U.S only).

Product Registration Information
Serial Number
First Name
Last Name
Title (if not enduser) or Parent/Guardian (if user is a child)
Facility
Address
Apt. / Room Number
City
State	Zipcode
Day Phone Number
Evening Phone Number
Email
	Send me the monthly "Standing Room Only" Newsletter View Sample Newsletter
Date of Birth MM/DD/YYYY	/ /
Height	ft in/cm
Weight	lbs/kg
Gender	Male Female

Disability (facilities please check primary diagnosis seen)
Date of Onset MM/DD/YYYY	/ /

	Paraplegic (level)
	Quadriplegic (level)
	Muscular Dystrophy (type)
	Hemiplegic
	Spina Bifida
	Head Injury
	Multiple Sclerosis
	Cerebral Palsy
	Other

Method of Payment

Is this your first stander? Yes No

If no, what brand was your last stander?

Rehab Technology Supplier / DME Vendor (person who you purchased your stander from)
Name
Company
Address
City	State Zip
Phone

Dr. or therapist who prescribed your stander
Name
Title
Name of Facility
Address
City	State Zip
Phone Number

How did you hear about Altimate Medical products?

If "other" :

What contact did you have with Altimate Medical prior to purchase?

If "other" :

How likely is it that you would recommend/prescribe EasyStand products to a friend/client?

What words would you use to describe our products? Our customer service?

What health & psychological benefits do you feel you receive the most from standing?

Why did you choose a stander from Altimate Medical? What do you like best about it?

You have my permission to quote from my comments & use these quotes in ads, brochures, mail and other promotions used to market your products. (not required, your EasyStand will still be under warranty if you do not agree)

yes no

Type the characters in the image above:

Fields in red are required.


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